Analysis Decision Making Given the gale warning issued by the Maritimes Weather Centre and the deteriorating weather, the operator of the 3J'S'93(THE) had to decide whether to continue fishing or to return to port. When faced with a decision involving risk, research indicates that there is a tendency to view the alternatives as a choice between gains or losses. People are biased towards the loss which is less probable rather than the uncertain loss, even if the less probable loss carries with it potentially disastrous consequences.[7] In this occurrence, the alternatives available to the operator both involved loss. A return to port without having fished all of the traps would result in a certain financial loss. On the other hand, to continue fishing, despite adverse weather, would increase the possibility of crew injury and/or of the vessel sustaining damage/ loss (an uncertain probability of disaster). The operator of the 3J'S'93(THE) and other fishing vessels in the area chose the latter alternative, which proved to be disastrous for the 3J'S'93(THE), over the sure loss of a diminished financial return on the catch. In contrast, the DFO vessel, which was not subject to the same financial considerations, returned to port within an hour of her departure. In an extremely competitive fishing environment with fish stocks subject to fluctuation, the loss of a full or part day's catch can create a shortfall in revenue to the fishermen. Hence, the operator's decision to continue fishing may have been influenced, in part, by the short lobster season and the good catch reported for the day. Although the operator was aware that heights of waves may be significantly higher in shallow waters than in deeper waters and despite the worsening weather conditions, he elected to transit the shallow (5-8 fathoms' depth) and rougher waters off North Cape instead of deeper (13-18 fathoms' depth) waters offshore; the latter route was used by other similar-sized vessels to safely transit the area. Further, the steep waves and breaking surf would cause the vessel to glide between the troughs. As the operator lost his life, it was not possible to determine why he had elected to take this route. Factors Affecting Capsize The absence of freeing ports and the small number and size of the scuppers in the transom would not permit rapid drainage of the water, but allowed some of the shipped water to accumulate on the well-deck. As the wheel-house door was left open, some of the shipped water found its way into the wheel-house. As the vessel was operating in a seaway, the transom scuppers would allow water shipped on deck to drain more readily when forward momentum was maintained than would be the case when headway was reduced. The reduction of speed would reduce the suction effect of the scuppers and also would result in loss of directional control. Additionally, because of the reduction of the vessel's forward speed, the momentum of the shipped water would cause it to flow through the open aft wheel-house door into the wheel-house. The weight of the water in the wheel-house would cause the vessel to trim by the head and submerge the bow. The matter of watertight openings and their importance in maintaining integrity was covered in Ship Safety Bulletin (SSB) 16/92. All small vessels of open construction employed in exposed or relatively rough waters are operated at risk, being particularly vulnerable to swamping by taking water over the gunwale, and prudent operation with regard to loading, freeboard, speed and orientation relative to the prevailing seas is essential for safety. The quantity of seas shipped over the port quarter resulted in the accumulation of water on the starboard side of the well-deck and its weight would cause the vessel to heel heavily to starboard. The situation would have been further aggravated by the unsecured fish pans and extractors moving to starboard and by the free surface effect of accumulated water on the well-deck. The cumulative effect of the above would cause the vessel to lose transverse stability and capsize. TP 8694 recommended against the carriage of fish outside the fish hold. Hand-hold on the Ship's Side The absence of hand-holds on the ship's side precluded the operator from gaining access to, or holding onto, the hull of the capsized vessel. Safety Equipment and Safety Drills There is no regulation governing the wearing of a life jacket or a personal flotation device (PFD) while working on the deck of a small fishing vessel or when the vessel is operating in adverse weather conditions. The approved life jacket required to be carried on fishing vessels must meet rigid buoyancy standards and have the ability to turn an unconscious person in the water to a face-up position. The life jacket design makes them cumbersome as a work attire. PFDs on the other hand provide freedom of movement and MOT-approved versions are on the market. However, PFDs are only aids to keep a person afloat in the water and are not a substitute for, nor intended to function as or replace an approved life jacket. In this instance, the life jackets were stowed in the cuddy and were not readily accessible. The rapidity of the capsize precluded the crew from gaining access to the life jackets. Hence, in the absence of a boat or inflatable liferaft requirement, the crew's prospect for survival was limited to accessing/donning of the life jacket and/ or the lifebuoy floating free. This occurrence once again highlights the dangers associated with overly relying on life jackets as the primary means to save lives, more so as they are rarely worn during operations. A competitively priced, practical alternative to a life jacket that can provide freedom of movement, some thermal protection, and reasonable flotation, and which is required to be worn while working on the decks of small fishing vessels or while the vessel is operating in adverse weather conditions can greatly enhance an individual's chances of survival in the frigid waters of Canada. Transport Canada, through various fora, has suggested or encouraged fishermen to use appropriate work suits, with both thermal and flotation capabilities. Although both crew members had worked together for approximately seven seasons, there was neither discussion between them nor was a plan in place to deal with shipboard emergencies. SAR-Related Issues Primary SAR resources, for the purpose of carrying out a marine SAR task, are designated government vessels, Hercules aircraft and Labrador helicopters, with crews specially trained in SAR. Secondary resources as defined in the NATIONAL SEARCH AND RESCUE MANUAL, are all resources of the Federal government that are not specifically dedicated to SAR but which may be tasked to aid in the resolution of a SAR incident. CCG helicopters are a secondary SAR resource. Although the CCG helicopter is a secondary SAR unit, there was no regime in place to ensure that RCC Halifax directly was apprised of the helicopter's return to base either by the ROC Maritimes or by means of the reporting practice similar to that of CCG vessels; a procedure adopted by other RCCs and MRSC. In this instance, the CCG helicopter's return to base was not indicated to RCC Halifax. Nonetheless, RCC Halifax normally receives a daily report, scheduling CCG vessels and their operational status, including CCG helicopters and hence, good operational practice dictates that consideration be given to its tasking (CCG helicopters) for a SAR occurrence. In this instance, RCC opted to task primary SAR air resources and the secondary resource was not considered. There was a communication deficiency between RCC Halifax and ROC Maritimes respecting SAR operations and reportedly, this is not an isolated occurrence. In the harsh marine environment where prompt tasking of SAR (marine/ air) resources is paramount to a positive resolution of a SAR occurrence, any delay in tasking an appropriate SAR unit unduly jeopardizes the safety of personnel. Further, while RCC Halifax is responsible for tasking SAR units, ROC Maritimes maintains up-to-date information on all government secondary resources in the area. Hence, closer cooperation between RCC and ROC, and a sound regime which ensures that RCC Halifax has up-to-date information on all secondary resources (available for SAR) is essential for the timely tasking of appropriate resources. The absence of the SARCOM line precluded timely input from ROC Maritimes with respect to the availability of all SAR resources. Good operational practice dictates that the procedures established in the SAR Manual for the seeking and tasking of SAR resources be followed. In this instance, they were not. The rapidity of the capsize precluded the operator from transmitting a MAYDAY. As no EPIRB was carried and as none was required to be carried, there would normally have been no means of alerting RCC of the vessel's need for assistance, resulting in delays to SAR response. In such an eventuality, the delay would reduce the crew's chances of survival. In this instance, it was fortuitous that the DFO officers on shore patrol saw the distressed vessel and promptly alerted the RCC. Despite deteriorating weather conditions, the 3J'S'93(THE) continued to fish all lobster traps before returning to port. The operator of the 3J'S'93(THE) elected to transit the rougher shallow waters rather than the relatively calmer deeper water further offshore. The reduction of the vessel's speed may have reduced the suction effect of the transom scuppers and could have resulted in loss of directional control. Additionally, the momentum of the shipped water caused it to flow through the open wheel-house door. The seas from the port quarter caused the shipped water to accumulate on the starboard side which listed the vessel heavily to starboard and caused the unsecured fish boxes to shift. The shipped water could not drain rapidly from the well-deck due to the absence of freeing ports and the limited number and size of scuppers. This allowed water to accumulate on the well-deck to the detriment of the vessel's transverse stability. The heel rapidly increased and the free surface effect of the water accumulated on the well-deck contributed to the vessel losing transverse stability and capsizing. The absence of hand-holds on the ship's side precluded the operator from gaining access to, or holding onto, the hull of the capsized vessel. The deck-hand, who was not wearing a life jacket, was suffering from mild hypothermia when rescued after some two hours of immersion in seawater. The operator was not wearing a life jacket and this substantially reduced his chances of survival. The sudden and unexpected capsize precluded the operator from either transmitting a distress message or from gaining access to the life jackets which were not readily accessible. There was no emergency plan in place nor was an emergency drill held. Neither was required by regulations. The vessel was not required to carry either a boat or an inflatable liferaft, and the crew's survival depended upon accessing/donning their life jackets. Life jackets are cumbersome as a work attire and consequently are rarely worn while working on the deck of a fishing vessel or while the vessel is operating in adverse weather. The absence of a practical alternative to a life jacket and the absence of a requirement to wear life-saving gear while working or operating in adverse weather conditions compromised crew safety and reduced the chances of survival in this emergency. The carriage of an EPIRB, voluntary or otherwise, has the potential to increase the chances of a distress alert being sent, thus leading to SAR resources arriving on scene in a more timely manner and increasing chances for survival. There was a communications deficiency between RCC Halifax and ROC Maritimes. RCC tasked primary SAR air units but the secondary SAR unit, a CCG helicopter, was not considered for tasking until some 12 hours after RCC Halifax received initial notification of this incident. There was no regime in place to ensure that RCC Halifax became aware of the CCG helicopter's return to base either through the ROC Maritimes or by means of the reporting practice similar to that used aboard CCG vessels. There was a communications deficiency between RCC Halifax and ROC Maritimes. RCC tasked primary SAR air units but the secondary SAR unit, a CCG helicopter, was not considered for tasking until some 12 hours after RCC Halifax received initial notification of this incident. There was no regime in place to ensure that RCC Halifax became aware of the CCG helicopter's return to base either through the ROC Maritimes or by means of the reporting practice similar to that used aboard CCG vessels. While transiting the shallow waters off North Cape in following and confused sea conditions, the 3J'S'93(THE) shipped heavy seas, and being unable to drain the seawater rapidly from the well-deck, lost transverse stability and capsized. Contributing factors to the capsize were the small size and limited numbers of the scuppers, the unsecured fish boxes and the free surface effect of liquids The operator was not wearing a life jacket or thermal protection, and this contributed to the loss of his life.Causes and Contributing Factors While transiting the shallow waters off North Cape in following and confused sea conditions, the 3J'S'93(THE) shipped heavy seas, and being unable to drain the seawater rapidly from the well-deck, lost transverse stability and capsized. Contributing factors to the capsize were the small size and limited numbers of the scuppers, the unsecured fish boxes and the free surface effect of liquids The operator was not wearing a life jacket or thermal protection, and this contributed to the loss of his life.